Diffuse TBI w LOC of 30 minutes or less, sequela

This code signifies the long-term effects or complications arising from a diffuse traumatic brain injury (TBI) where the initial loss of consciousness (LOC) was brief, lasting 30 minutes or less. It indicates that the patient is experiencing residual symptoms or conditions directly attributable to this past head trauma.

Apply this code when documenting a patient presenting with sequelae (e.g., cognitive deficits, post-concussive syndrome, persistent headaches, mood changes) from a previously sustained diffuse TBI with a documented LOC of 30 minutes or less. The "S" seventh character indicates that this is a sequela code, used for conditions that are the late effects of the initial injury.

• Always sequence this code after the code(s) for the specific sequela being treated (e.g., G44.3 for post-traumatic headache).
• Ensure documentation clearly links the current symptoms to the past TBI and specifies the duration of the initial LOC.
• Do not use this code for acute TBI encounters; it is exclusively for the late effects of the injury.